ENGLISH NURSING ASSIGNMENTS

ARRANGED BY :

NAME : ETI JUNIA ASTUTI

NIM : 029STYC 17

ISLAMIC HOSPITAL FOUNDATION OF NUSA TENGGARA BARAT

HIGH SCHOOL OF HEALTH SCIENCE YARSI MATARAM
NURSING SCIENCE STUDY PROGRAM BACHELOR DEGREE
MATARAM 2019/2020
TASK 1

1. Search and explain the patients medical records in English.

. Based on REGULATION OF THE MINISTER OF HEALTH OF THE

REPUBLIC OF INDONESIA NUMBER 269 / MENKES / PER / III / 2008
CONCERNING MEDICAL RECORDS Article 3, namely:

1. The contents of the medical record for outpatients in health care facilities at
least contain :
a. Patient identity
b. Date and time
c. Anamnesis results, including at least complaints and history of the disease
d. Results of physical examination and medical support
e. Diagnosis
f. Management plan
g. Treatment and / or action
h. Other services that have been provided to patients
i. For dental case patients equipped with a clinical odontogram
j. Approval of actions if needed
2. The contents of the medical record for inpatients and one-day care at least
contain :
a. Patient identity
b. Date and time
c. Anamnesis results, including at least complaints and history of the disease
d. Results of physical examination and medical support
e. Diagnosis
f. Management plan
g. Treatment and / or action
h. Approval of actions if needed
i. Clinical observation records and treatment results.
j. Return summary (discharge summary)
 k. Names and signatures of doctors, dentists or certain health professionals
who provide health services
l. Other services provided by certain health workers
m. For dental case patients equipped with a clinical odontogram.
3. The contents of the medical record for emergency patients include at least:
a. Patient identity
b. Conditions when the patient arrives at a health care facility
c. The patient's introductory identity
d. Date and time
e. Anamnesis results, including at least complaints and history of the disease
f. Results of physical examination and medical support
g. Diagnosis
h. Treatment and / or action
i. Summary of the patient's condition before leaving the emergency services
and follow-up plans
j. Names and signatures of doctors, dentists or certain health professionals
who provide health services
k. Means of transportation used for patients who will be transferred to other
health care facilities
l. Other services that have been provided to patients

Example :

MEDICAL RECORD DOCUMENT

Patien identity
Name :
Name family card :
Profession :
Address :
Gender :
Age :
Religion :
Eduation :
Marital status :
No telepon :
a. Date :
What date the patient came
b. Anamnesa:
Ask complaints or conditions of the patient
c. Physical examination:
Examination ttv, Head to to, And others
d. Diagnosis:
The consclusions generated from the data analysis
e. Therapy:
Therapy given by the doctor
f. Paraf :
Doctor’s sighnature